GRASSROOTS: The GMT Initiative Blog

Grassroots reports on the work of amfAR-supported research teams and advocates responding to the devastating impact of HIV among gay men, other men who have sex with men, and transgender individuals (collectively, GMT).

Recently, I visited Johnny Tohme, a 2013 amfAR HIV Scholar, in Beirut, Lebanon, to find out how his GMT Initiative-supported research on HIV among GMT refugee populations from Syria, Iraq, and Palestine is going. While learning about Johnny’s interesting and groundbreaking project, I also had the opportunity to meet with Cynthia Al Khoury, who works for MARSA, a sexual health clinic serving many populations, but specifically targeting MSM and trans individuals. It is the only clinic in Lebanon doing this work, and it has so many clients that the healthcare workers could not meet with us until after hours.

Cynthia Al Khoury crosses the clinic lobby. The clinic’s trans health program is in its second year and grew out of Cynthia’s thesis for her Master’s degree in Public Health. I found it exciting that Cynthia was able to take her thesis from paper to reality—and so did she. “I never expected my thesis to grow into anything substantial, much less a formal health program for such a stigmatized population,” she said.

While being gay is criminalized in Lebanon, and there are strict social codes that forbid same-sex sexual behavior, it is considered to be one of the most LGBT-friendly Middle Eastern nations. There are LGBT bars and clubs—though they remain inconspicuous—and the younger generation seems more open to accepting LGBT people. In Lebanon, trans individuals are able to legally change their gender on their national identity documents, which is unusual in a country where homosexuality is illegal, and there are no laws against being transgender. However, societal stigma and discrimination against trans individuals is strong, causing barriers to education and employment. This leads many trans individuals in Lebanon to practice sex work to make a living, which puts them at high risk of HIV infection.

Johnny Tohme waits in the clinic lobby.I asked Cynthia if there were any epidemiologic data about HIV among trans individuals, and she smiled, confirming what I already knew. There is no data available, and the government does not have any HIV programs targeting GMT individuals. But she reported that the HIV prevalence she has seen among the population seems to corroborate global data showing they have a higher prevalence than men who have sex with men (MSM) and a much higher rate than the general population. I asked her if she thought the Lebanese government would ever consider providing PrEP for trans individuals, and she said she hoped one day that conversation could be had, though it has not yet been a possibility. “I have tried to have that conversation, and it was shut down before the conversation was even begun,” she said sadly.

MARSA currently has 19 trans clients actively enrolled in medical care, and Cynthia happily reported that they are welcoming more trans clients each month. The MARSA trans health program has trained community leaders in the trans community to educate and mobilize trans individuals and to let them know that MARSA offers free HIV preventive and treatment services and free mental healthcare. And while MARSA cannot afford to offer hormone treatment (prescription hormone therapy and sexual reassignment surgery are legal but scarce and prohibitively expensive), they do provide risk-reduction counseling for those who self-administer hormones that can be purchased on the street, which are potentially dangerous.

Overall, I was encouraged to see that MARSA had a functioning program for GMT individuals in the Middle East that is gaining the trust of its clients despite the tough legal and social situation that many face. The clinic is beautifully maintained, with staff who are friendly and welcoming, and it is definitely a place I would go for health services.

Many of us have been saddened by the magnitude of loss caused by last week’s earthquake in Nepal. But daily I am heartened to hear about the tremendous relief efforts that are happening and workers’ success in finding individuals still alive after so many days. Earthquakes can be challenging for humanity, especially when they happen in low-income countries, but the rush to offer assistance is truly what makes us human.

However, I cannot help but think back to the discrimination experienced by LGBTI in Haiti in the wake of the terrible destruction caused by their 2010 earthquake. The relief community’s response was swift, but it lacked assistance targeted to LGBTI individuals and people living with HIV, who, due to extreme stigma and discrimination, often lack access to stable housing and familial support, making them especially vulnerable to the ravages of earthquakes and other natural disasters.

When they sought help at general relief sites, many LGBTI experienced overt stigma and discrimination. This included horrendous sexual violence perpetrated against trans men and women and effeminate gay men in temporary housing and the exclusion of trans women and men from all gender-specific services. Despite this, aid agencies did not—and still do not—establish services targeting LGBTI as part of their disaster relief.

Unfortunately, amfAR is beginning to hear similar reports coming from Nepal of discrimination against LGBTI and people living with HIV. Since the earthquake, we have been in touch with colleagues at the Blue Diamond Society (BDS), a long-term partner and grantee of amfAR’s and the leading HIV advocacy and LGBTI rights organization in Nepal. They report that a few key staff members were killed or injured during the earthquake and that the building housing their main office and community center sustained structural damage.

Despite these losses, they have started taking action to provide discrimination-free services for the Nepalese LGBTI community and advocate for aid agencies to recognize the unique challenges faced by marginalized people in society—namely LGBTI individuals and those living with HIV. Hopefully the larger aid and relief agencies will hear their call.

However, one way to help ensure that the response caters to the needs of all affected people in Nepal is to fund BDS directly. They have set up mechanisms for colleagues in other countries to support them through FIAR, the Foundation for Integrative AIDS Research, and the Rainbow Fund. (Be sure and write “Nepal–Blue Diamond Society” in the notes section on the Rainbow Fund site.)

And here is the call from Blue Diamond Society itself:Members of the Blue Diamond Society, the Health and Opportunity Network (HON), the Thai Transgender Alliance (ThaiTGA), Transgender and Intersex Africa (TIA), and the GMT Initiative during an advocacy exchange meeting in Nepal organized by amfAR

Dear All,

It’s as clear as the daylight that LGBTIs in Nepal are equally affected if not more. When disrepair hits, marginalized, excluded, and vulnerable communities suffer the most. The needs are enormous in Nepal and different aid agencies and government have their own priorities, but these priorities should be based on facts, needs, and urgency rather than based up on cultural/social biases or your own agency’s traditional approaches that have usually overlooked LGBTIs. For example, we have seen that some of the toilets constructed around relief camps are only based on binary gender mechanisms, excluding third gender propitiation. Queues for "Rashan" and other aid kits are the same, based on binary genders.

We call on Nepal’s government, USAID, DFID, NORAD, UNDP, GIZ, Oxfam, and the other aid agencies to actively and purposefully include LGBTI in their response and rehab programmes. We also call our follow LGBTI rights organizations around the world to join forces to encourage USAID, DFID, Norad, UNDP, GIZ, Oxfam, and the other aid agencies to actively and purposefully include LGBTI in their response and rehab programmes. This might mean a joint communique or a statement.

Thank you very much for your kind thoughts, generosity, and solidarity.